304312594-6-5-2019-06-CC-DVAA-BCTPQ5-20190604113034

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304312594
Report Date: 06/04/2019
Date Signed: 06/05/2019 08:21:00 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	DECASAS, MARSI		FACILITY NUMBER:	304312594
ADMINISTRATOR:	DECASAS, MARSI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 291-8826
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY:	14	CENSUS: 7	DATE:	06/04/2019
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Marsi Decasas		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An inspection was conducted at the facility by LPA, Dean Valencia. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently 3 adults living in the home. During today’s inspection the home and grounds were toured and the licensee was operating within the licensed capacity. There were 7 children in care at the time of the inspection. It was observed that the provider is operating within compliance of ratio, and a printout of ratio was provided and discussed. Operating hours are 8:30am to 1:30pm, Mon–Fri. The floor plan was verified. Off limits areas are made inaccessible by means of baby gate, and fences. The licensee's pediatric CPR/First Aid certification is current, which expires 3/3/2020. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Poisonous items are not stored on site, and none were observed during today's inspection. There is a working carbon monoxide detector, smoke detector, and fire extinguisher in the home. The licensee has a current roster of children in care. The facility has conducted an emergency drill within the past six months, and is documenting these drills. The firearms and the ammunition were verified to be locked separately and inaccessible to children. The children use the backyard as the outdoor play area, and it is completely fenced, and is free from hazards. There are no bodies of water on the premises. Children's records were reviewed, and were found to be missing some documentation. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm . (continued on LIC809C)

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: DECASAS, MARSI	FACILITY NUMBER: 304312594
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)

Records - Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
	Deficient Practice Statement
1 2 3 4	Based on review of documentation, it was determined that two of the seven children's files did not have immunization records available for review. This is a potential threat to the children's health and safety.
	POC Due Date: 07/02/2019
	Plan of Correction
1 2 3 4	The licensee stated that she will submit the two children's immunization records to LPA, by 7/2/19. LPA's contact information was left with licensee.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2019

LIC809 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: DECASAS, MARSI	FACILITY NUMBER: 304312594
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Records - Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).
	Deficient Practice Statement
1 2 3 4	Based on a review of the children's files, it was determined that all files reviewed did not have a signed LIC995A available to review. This is a potential threat to the children's health and safety.
	POC Due Date: 07/02/2019
	Plan of Correction
1 2 3 4	The licensee stated that she will submit the records to LPA, by 7/2/19. LPA's contact information was left with licensee.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2019

LIC809 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: DECASAS, MARSI	FACILITY NUMBER: 304312594
	VISIT DATE: 06/04/2019

NARRATIVE

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Proof of immunization against pertussis, influenza (or written declination), and measles for licensee(s)/assistants/volunteers within compliance of SB 792, were not available to review.
The licensee was advised on how to receive notifications about quarterly updates, and provided with the Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov
A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Safe Sleep Regulation Concepts (4/2018) was provided for the Licensee. LPA discussed safe sleep and new safe sleep concepts with the provider. Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years, per A.B. 1207. This training was discussed with provider, and certification of this training was reviewed. The provider was given a pamphlet on Lead Exposure and was discussed with provider.

Exit interview was conducted, and this report was reviewed and discussed. Notice of Site Visit was posted during the visit. The licensee was informed that the Notice of Site Visit must be posted for 30 consecutive days from today's date. Failure to post and remain posted will result in civil penalties of $100 per day. The licensee was provided a copy of their appeal/licensee rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional manager, office address is on page 1 of this report. The licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. and accessibility/information about the website was discussed with the provider. This report is to be on file and accessible for public review at the facility, for the next 3 years.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see attached LIC 809D.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2019

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: DECASAS, MARSI	FACILITY NUMBER: 304312594
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

Records - Family Day Care Homes

(1)Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
	Deficient Practice Statement
1 2 3 4	Based on a review of staff records it was determiend that three adults assisting with care did not have proof of immunizations against pertussis, influeza (or written declination), and measles on file.
	POC Due Date: 07/02/2019
	Plan of Correction
1 2 3 4	The licensee stated that she will submit the staff's immunization records to LPA, by 7/2/19. LPA's contact information was left with licensee.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2019

LIC809 (FAS) - (06/04)

Page: 5 of 5